Nursing Elites

1. Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of ineffective airway clearance. Which assessment data best supports this diagnosis?

• A. Weak, nonproductive cough effort
• B. Large amounts of greenish sputum
• C. Respiratory rate of 28 breaths/minute
• D. Resting pulse oximetry (SpO2) of 85%

Correct answer: A

Rationale: The correct answer is 'Weak, nonproductive cough effort.' A weak, nonproductive cough indicates that the patient is unable to clear the airway effectively, supporting the nursing diagnosis of ineffective airway clearance. In pneumonia, secretions can obstruct the airway, leading to ineffective clearance. Choices B, C, and D do not directly reflect ineffective airway clearance. Large amounts of greenish sputum (Choice B) may suggest infection or inflammation but do not specifically indicate ineffective airway clearance. The respiratory rate of 28 breaths/minute (Choice C) and a resting pulse oximetry (SpO2) of 85% (Choice D) are more indicative of impaired gas exchange or respiratory distress rather than ineffective airway clearance.

2. When assessing a patient who has just arrived after an automobile accident, the emergency department nurse notes tachycardia and absent breath sounds over the right lung. For which intervention will the nurse prepare the patient?

• A. Emergency pericardiocentesis
• B. Stabilization of the chest wall with tape
• C. Administration of an inhaled bronchodilator
• D. Insertion of a chest tube with a chest drainage system

Correct answer: D

Rationale: The patient's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube and drainage. Emergency pericardiocentesis is not indicated as the patient's symptoms are not suggestive of cardiac tamponade. Stabilization of the chest wall with tape would not address the underlying issue of a potential pneumothorax or hemothorax. Administration of an inhaled bronchodilator is not appropriate in this scenario as the patient is not exhibiting signs of asthma or bronchoconstriction. Therefore, the correct intervention for this patient is the insertion of a chest tube with a chest drainage system to address the potential pneumothorax or hemothorax.

3. A 24-year-old female contracts hepatitis from contaminated food. During the acute (icteric) phase of the patient's illness, what would serologic testing most likely reveal?

• A. antibody to hepatitis D (anti-HDV).
• B. hepatitis B surface antigen (HBsAg).
• C. anti-hepatitis A virus immunoglobulin G (anti-HAV IgG).
• D. anti-hepatitis A virus immunoglobulin M (anti-HAV IgM).

Correct answer: D

Rationale: Hepatitis A is primarily transmitted through the oral-fecal route. During the acute phase of hepatitis A, serologic testing typically reveals anti-hepatitis A virus immunoglobulin M (anti-HAV IgM). This antibody appears early in the course of the infection. The presence of anti-HAV IgM indicates an acute infection with hepatitis A. Choices A and B are incorrect as hepatitis D and hepatitis B antigens are not typically associated with acute hepatitis A. Choice C, anti-hepatitis A virus immunoglobulin G (anti-HAV IgG), would indicate a past infection and lifelong immunity, which is not expected during the acute phase of the illness.

4. A patient has been taking mood stabilizing medication but is afraid of needles. They ask the nurse what medication would NOT require regular lab testing. What is the nurse's best response?

• A. Valproic Acid (Depakote)
• B. Clozapine (Clozaril)
• C. Lithium
• D. Risperidone (Risperdal)

Correct answer: D

Rationale: The correct answer is Risperidone (Risperdal) because it is the only medication among the options that does not require regular lab testing. Risperidone is not associated with the need for routine blood draws to monitor medication levels or potential side effects. Choices A, B, and C (Valproic Acid, Clozapine, Lithium) are all known to require frequent lab monitoring due to various reasons such as potential toxicity, therapeutic drug levels, or adverse effects on certain organ functions. Therefore, considering the patient's fear of needles and the desire to avoid frequent blood tests, Risperidone would be the most suitable option.

5. A nurse is educating a patient about bimatoprost (Lumigan) eyedrops for the treatment of Glaucoma. Which of the following indicates that the patient has a correct understanding of the expected outcomes following treatment?

• A. "I should be experiencing less blurriness in my central field of vision"
• B. "This medication won't help my vision at all, but will keep it from getting worse."
• C. "My peripheral vision should be increasing back to its normal state, but will take a few weeks to do so."
• D. "This medication will help my eye restor intraocular fluid and increase intraocular pressure"

Correct answer: B

Rationale: Glaucoma cannot be cured, just treated. Treatment revolves around preventing further deterioration.

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